low placenta - doc wants to schedule c section - trying to assess risks - Mothering Forums

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#1 of 24 Old 05-30-2008, 02:14 PM - Thread Starter
 
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Hi All. Newbie here....this is my first post. A friend from another site said that maybe I could find some help here. I'm 38 weeks pregnant with my second child, and I have a low placenta, and I'm trying to avoid C section if I can do so without taking irresponsible risks. I tend to go on and on and on when I post, so I'm going to try to keep this short and to the point.

-I live in Athens, Greece. We have an out-of-control C section rate here, an awful induction rate, and a "don't question the doctor" culture. (My husband is Greek. I am American.)

-My first baby, born 2.5 years ago, was 9 lbs even, induced, born 6 hours exactly after the pit IV was put in my arm. (Induced because my doctor had another patient delivering that night--I was 2 days overdue, not in labor at.all.) Uncomplicated vaginal delivery--but a huuuuuuge episiotomy (doc didn't even *tell* me she was cutting it....but that's another post).

-With this pregnancy, I wanted a totally different experience--no epidural, NO INDUCTION. I would love a homebirth but when I mentioned it to my husband his head nearly exploded. I chose a natural birth clinic, the only one in Greece, which is part of an older maternity clinic which can do C sections but apparently is not equipped to do blood transfusions. I've had a completely uncomplicated pregnancy--I've never even thrown up.

-At 22 weeks, ultrasound revealed that my placenta was touching my cervix, but the doctor assured me that it would "move up". (I've read as much as I can about this, I know they don't actually move, just appear to as the uterus grows.)

-At 32 weeks, ultrasound (transabdominal) revealed that the placenta was 2.3 cm from the cervical os. Ultrasound doc said don't panic, it still has time to move, see what your OB says at 36 weeks.

-At 36 weeks, my OB (Dr. Bilalis), whom I chose because he's supposed to be natural-birth friendly and delivers at the natural birth clinic (which is considered very VERY treehuggerfringe by the Greek mainstream), made a face at the 2.3cm measurement and said we'll see if it has moved, but it doesn't look good, and if it hasn't moved it looks like C. He has an ultrasound machine in his office, and with trans-vaginal ultrasound measured 2.4 cm. Seemed very pessimistic and said he'd see me in 2 weeks but if it hadn't moved he thought we should schedule C in the 39th week. He pretty much terrified my husband, telling him that if I hemorrhage it could be really, really bad, and that it is a good thing that we're 15 minutes from his hospital, and that the first sign of ANY blood I needed to get to the hospital.

-I've done a lot of reading about placenta previa and low lying placenta since the 32 week ultrasound, and I knew already that many articles say that if the placenta is more than 2 cm from the cervical os, a trial of vaginal labor stands a good chance (greater than 60% in some articles, just "good chance" in others) of success. I wanted to line up some second opinions since this doc seemed SO negative.

-I spoke over the phone to one doc who knows my doc---he said he'd allow a trial of labor in my case but that he really respects my doc, good training (in the UK--they trained there together), etc etc, and I should go back to my doc and present my concerns, blah blah. Basically I think he wouldn't take me as a patient because of a professional relationship with my doc.

-I spoke over the phone with another doc, a German woman much-respected in the expat circles here, who apparently does VBACs (and thus isn't totally risk-averse, at least not by Greek standards). She said she'd do a C for anything under 5cm, totally validating *my* doc's position.

-At 37 weeks 1 day, I met with yet another doc (Dr. Kalabani), who was recommended to me by one of the midwives who works at the natural birth clinic. She said 2.4cm "is not a problem". She wanted to meet with me, though, and do yet another ultrasound. We met with her and she was very reassuring. They did the ultrasound (trans-abdominal, which I understand is less accurate than trans-vaginal), and measured the distance at 4cm (just 1 week 1 day after the 2.4 trans-vag measurement with Dr. Bilalis). They said the placenta was "far away", that anything over 2 cm was OK, and that the baby's head was below the edge of the placenta. Dr. Kalabani said I should expect to deliver in the hospital, not the natural birth clinic, as the hospital is better equipped in CASE things turn ugly, but that she saw no reason for me to expect anything other than a successful vaginal delivery. She said that as the baby's head descends, it would cut off any bleeding, and she wasn't worried about hemorrhage.

-Last night, at 37 weeks 6 days, we went back to Dr. Bilalis. I wanted to get a better understanding of the risks of hemorrhage, see if he would back off on the C section if I told him about all that I'd read and that I wanted a trial of labor. Before we had any discussions, he repeated the trans-vaginal ultrasound, and said "it hadn't moved since 32 weeks". I said, what is the distance? He said, 2.3, 2.4 cm. He said the placenta (anterior placenta) was between the baby's head and the cervical os. Then I gave him my spiel about what I'd read, about the fact that I'm American and Americans seek second opinions on serious issues, told him about my discussions with other doctors, told him about the other ultrasound with the 4cm measurement, told him about the medical articles I'd found that repeatedly say that with more than 2 cm, a trial of labor is appropriate. He asked who the patients were in these studies, so I brought out printouts with what I saw as the relevant bits highlighted. He told me he'd "allow" me to go to 40 weeks, on the off chance I went into labor, which he didn't think would happen as the placenta would prevent the baby's head from descending. He said that if the placenta was posterior, it might be different, but with an anterior placenta that he didn't think the baby's head would descend. He told me the "right" thing to do was to schedule the C section for next week, but that he'd "allow" me to go to 40 weeks, but not one day over: "I won't even discuss it." He repeated all that he'd said previously about how I was at risk of serious hemorrhage in which 5 minutes could make a difference, and I could die, blah blah blah. This has all really sunk into my husband's head, and in spite of hearing the exact opposite from Dr. Kalabani not even a week ago, he is *freaked* out and I know he basically wishes I'd do the C next week. I'm not typing it all out here but the conversation with Dr. Bilalis got really ugly. Doctors in Greece are not used to being questioned by patients and it quickly degenerated into him telling me that "now you're just fantasizing that you don't have this complication", calling every point I made in my questions "invalid", refusing to discuss the conditions of vaginal birth at his hospital (the one where he does most deliveries, since most Greek women won't do the no-epi natural birth center, and the hospital where my daughter was born--where you are only permitted to labor and deliver flat on your back, etc) because there was a ".001% chance of vaginal delivery", "well I guess you know more than I do, why don't you go find a hospital that has policies you approve of and a doctor who will tell you things you want to hear". My husband says there was yelling on both sides, but I had planned this conversation in my head and was actively trying to keep it from getting too confrontational.....it was awful. Really awful. As soon as I was out of the office, I lost it, and I pretty much cried for the rest of the night.

-My husband has tried to appear sympathetic, but Dr. Bilalis has scared the proverbial sht out of him....what he really wants me to do is give in and schedule the C.

-What I really want to do is have my trial of labor with Dr. Kalabani, at *her* hospital, which is more labor-friendly and has birth pools, etc. But Dr. Bilalis has scared me with his horror stories, too.

-Mitera (Dr. Bilalis' hospital), is about 15 min drive from our house. Lito (Dr. Kalabani's hospital) is about 30-40 minutes drive, maybe worse with traffic which can be awful and unpredictable here.

So, if you've read through ALLLL that, thank you sooo much. What I need help with is understanding the risk I'm taking if I go with the trial of vaginal delivery with Dr. Kalabani at Lito. Is the extra 20 minutes distance to the hospital critical? What am I *really* risking, if I start to hemorrhage at home? What are the chances of this? I've heard the bleeding can be really really bad......but I've heard this from the 2 doctors that would go to C immediately in my case. What am I risking? I don't want to take irresponsible risks. I look at my little girl, and I really don't want to bleed to death....the idea of leaving her motherless gives me a bigger push toward that C than anything else. But....I don't want to live the rest of my life wondering if everything with this birth would have gone just fine if I'd just let nature take its course, either.

Does anyone have real life experience with a situation like mine? Can anyone give me advice, or tell me anything more about how real the risk of hemorrhage is for me? And how bad the hemorrhage could be?

Thanks so much to anyone who can help me with this. It's been an awful two weeks for me. I just wanted this birth to be so different from this.....
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#2 of 24 Old 05-30-2008, 02:30 PM
 
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I have no advice, I just really wanted to let you know that you are amazing. All the second (third, fourth) opinions are way more than most people would even consider. Way to go you!! Sending wonderful, peaceful, easy, VBAC vibes your way and hoping someone here will have the answers you seek.

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Sometimes the greener grass is actually AstroTurf, a false promise and nothing more.
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#3 of 24 Old 05-30-2008, 03:05 PM
 
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Not a midwife, but I wanted to chime in with a hug : and my non-medical opinion. Seriously, huge kudos to you for seeking out more than one medical opinion.

If I were you, I'd:

- go with Dr. Kalabani and the farther hospital; I would be much less worried about the distance and WAY more worried about a knife-friendly OB...it sounds like he wants any excuse for a section, and even if it's not bleeding, he'd find another excuse during labor. Here in my city, my clients choose hospitals that are this distance away and would take longer in traffic and I've not had a car birth, yet. We have a very high section rate, so it is worth it to them to choose a more "friendly" hospital.

- no matter who you choose to use as an OB, try to find a doula (if this is a possibility in Greece? I have no idea) who can help you decide when in labor to get in the car to go to the farther hospital and can help advocate for you for a natural birth. your husband is rightfully scared, and he may not be able to advocate for you in the ways you'd want during labor...especially when/if doctors/nurses come at you with scare tactics.

Many good wishes to you for a successful, wonderful natural birth.

Allyson - wife, mama, midwife
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#4 of 24 Old 05-30-2008, 03:16 PM
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I guess my question would be why the first doctor thinks that if you go into labor before 40 weeks it would be okay to try but at 40 weeks you should just have a section. To me it would seem that a trial of labor is a trial of labor whether it occurs at 39.6 or 40.1 . I am no expert in this subject, but I think the other doctor is a little more reasonable. A trial of labor in the hospital with the understanding that a c-section is a possibility if there is severe bleeding.

It sounds like the second hospital would be a better place to give birth. I do think it is quite reasonable to stay away from the birth center since the issue is blood loss. I also think that if you meet the first doctor's 40 week deadline to labor he will be very quick to section during labor and you would have to be leery of that.

If you started to labor at home and started to hemorrhage I think you would obviously go to the closest hospital. I wouldn't labor at home for a long time in your case. It is scary to balance the fears. Another way to look at it is that if you had only seen the second doctor you would now be under the impression that everything is fine and no worries... now it is nice to be aware of the first doctor's concerns but just to put it in perspective.
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#5 of 24 Old 05-30-2008, 03:26 PM
 
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I agree you should switch to Dr. Kalabani and go to the further hospital.

I had no idea the birth culture was so awful in Greece!
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#6 of 24 Old 05-30-2008, 03:28 PM
 
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I have no advice but only loving support.
I read the whole post and whatever the outcome you have already done due diligence. BTW. Greece sounds exactly like giving birth in NYC! So don't think for one minute a doctor in the states would treat you any differently!

I personally would go with Dr. Kalabani who will allow labor, if it makes your husband feel safer labor in that hospital instead of staying home.

Whatever the outcome you will have a wonderful birth!
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#7 of 24 Old 05-30-2008, 03:45 PM
 
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I guess my question would be why the first doctor thinks that if you go into labor before 40 weeks it would be okay to try but at 40 weeks you should just have a section. To me it would seem that a trial of labor is a trial of labor whether it occurs at 39.6 or 40.1 . I am no expert in this subject, but I think the other doctor is a little more reasonable. A trial of labor in the hospital with the understanding that a c-section is a possibility if there is severe bleeding.
VERY good question.

Physiology tells us that the OP's placenta is moving away from the cervix as her uterus grows. At 39 weeks the uterus and baby are still growing, and at 40 weeks it stands to reason that the placenta will have moved further away from the cervix.

I'd run from the first DR, and never look back. If you stay, you've got a 99.9% chance of having a cesarean.

April :
Mom, Wife, Doula, CBE
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#8 of 24 Old 05-30-2008, 04:15 PM
 
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I say go with your gut feeling but my personal choice would be Dr. Kalabani.
I had a really bad doc last time and it's not worth it.

From what I see in your case, it sound like your first doc is a bully and not going to listen to you. You need someone that will at least take your wishes into consideration. I also think it would be good for you to sit down with Dr. Kalabani with your hubby again and tell her that you would like to go over again what could happen and what will likely happen to help put your hubby at ease. Best wishes.

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#9 of 24 Old 05-30-2008, 04:23 PM
 
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Not a BP, but sending lots of support and adding my voice to the "yay you" crowd!

FWIW, a good friend of mind in Paris had partial previa (I think she was 2cm) and was given a trial of labour. She did end up bleeding excessively and having a section, but her OB at the high risk hospital in Paris felt it safe to try (she has cancer and was already a patient of the head of OB in that hospital) (yup, already cancer and then previa too - couldn't catch a break!!).

GL, please KUP.
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#10 of 24 Old 06-02-2008, 06:02 PM
 
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I am curious to see how things turn out for you?
Hope things are better.

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#11 of 24 Old 06-02-2008, 06:40 PM
 
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I know at our hospital if a patient has an early previa or low lying placenta with a follow up ultrasound that shows the placenta >2cm from the cervix, they are allowed to have TOL. (And the ones I have cared for it has been a non-issue, normal labor, normal Vaginal del) Have you had any bleeding? Are you effacing/dilating? I agree with the above posters...if it were me personally, I would go with Dr. K even being a little further. Dr. B sounds like a bully with his agenda already set. I can only imagine you showing up in active labor with normal bloody show and him telling you it's too much and you will bleed to death and want to do a C to "prove his point" kwim? I'm not sure what the placenta being anterior vs posterior has to with a TOL being riskier...maybe someone can enlighten me. A C-section with an anterior placenta (especially low lying) is riskier and you have more bleeding, because to do a low transverse, they will actually have to cut through the placenta...

Laura...part-time OB nurse, and full-time mom to two sweet boysnocirc.gifintactlact.gif
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#12 of 24 Old 06-02-2008, 06:52 PM
 
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I know at our hospital if a patient has an early previa or low lying placenta with a follow up ultrasound that shows the placenta >2cm from the cervix, they are allowed to have TOL. (And the ones I have cared for it has been a non-issue, normal labor, normal Vaginal del) Have you had any bleeding? Are you effacing/dilating? I agree with the above posters...if it were me personally, I would go with Dr. K even being a little further. Dr. B sounds like a bully with his agenda already set. I can only imagine you showing up in active labor with normal bloody show and him telling you it's too much and you will bleed to death and want to do a C to "prove his point" kwim? I'm not sure what the placenta being anterior vs posterior has to with a TOL being riskier...maybe someone can enlighten me. A C-section with an anterior placenta (especially low lying) is riskier and you have more bleeding, because to do a low transverse, they will actually have to cut through the placenta...
I think the bolded part bears some thought. Or what if the doc decided that he didn't want to bother with a low transverse incision and instead gave you a classical one?! That would not be cool.
I'd go with the doc that seems to have some sense of moderation and at least willing to discuss w/you, not disrespect you.
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#13 of 24 Old 06-02-2008, 07:50 PM
 
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Switch doctors. Go for it. Try homeopathic Cinnamomum 200C twice a day for three days. It moves placentas. Worked for my 2cm low lying last time. Best wishes!
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#14 of 24 Old 06-03-2008, 12:46 AM
 
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2 cm from the os gives you plenty of room and you're not even in labor yet! Don't let them cut you!
Good luck!

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#15 of 24 Old 06-03-2008, 01:14 AM
 
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Don't want to scare you but if it is low and anterior another thing to think about is placenta accreta, where the placenta grows into the scar, but that is very rare. I had a little different situation, low, anterior, but it started bleeding at 35 wks, so I had a RCS. Which worked out good because it was an accreta. I would just go with your gut, always trust your instincts.

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#16 of 24 Old 06-03-2008, 01:43 AM
 
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I can't remember if mine was anterior or posterior, but my placenta was 2.4 cm away from the os, and I had a fantastic home water birth... sending you lots of hugs! I wish you a great and eneventful birth...
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#17 of 24 Old 06-03-2008, 09:54 AM
 
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Don't want to scare you but if it is low and anterior another thing to think about is placenta accreta, where the placenta grows into the scar, but that is very rare. I had a little different situation, low, anterior, but it started bleeding at 35 wks, so I had a RCS. Which worked out good because it was an accreta. I would just go with your gut, always trust your instincts.
She doesn't have a scar...she had a previous uncomplicated vaginal delivery.

Laura...part-time OB nurse, and full-time mom to two sweet boysnocirc.gifintactlact.gif
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#18 of 24 Old 06-04-2008, 09:55 AM
 
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Oh sorry. I actually didn't mean to post in Birth Professionals. Again sorry, didn't mean to cause anything.

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#19 of 24 Old 06-04-2008, 10:04 AM
 
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Schedule a c-section with Dr. B's office for 43 weeks, then go in at 40-42 weeks and have a lovely birth with Dr. K, and call up and cancel the c-section appointment. "Sorry, can't make it, have to spend time with the baby!"
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#20 of 24 Old 06-04-2008, 11:03 PM
 
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I don't think you should let a provider who argued with you to touch you again. Period. Hopefully this is something that your husband can really understand as the bottom line. This man was not interested in praising your for your research and caring about your body and respectful of your reticence in wanting to avoid major surgery. Furthermore, if you had cancer and did your research no one would blink and eye, why should it be different in obsterics...this is a very important point...the doc was unprofessional. You do not want someone caring for you who cares more about his ego than your body/mind.

If you are in-hospital hopefully your husband will be happy, so if needed you could get a c/s. 30 min away should not be a problem, especially for someone who has had no bleeding prenatally. Also, next visit with dr. k, ask her to do a Transvaginal for reassurance regarding her 4cm abdominal assesment.

Honestly, anything after 2cms is a TOL situation and ant/post position is not something to be considered from what I know...I think the doc didn't like to be challenged and lashed out at you.

Best of luck, can't wait to hear your birth story!
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#21 of 24 Old 06-04-2008, 11:41 PM
 
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I don't think you should let a provider who argued with you to touch you again. Period. You do not want someone caring for you who cares more about his ego than your body/mind.

Also, next visit with dr. k, ask her to do a Transvaginal for reassurance regarding her 4cm abdominal assesment.

Honestly, anything after 2cms is a TOL situation and ant/post position is not something to be considered from what I know...I think the doc didn't like to be challenged and lashed out at you.

Best of luck, can't wait to hear your birth story!
: And to add to that, I would wait to leave for Dr. K's hospital when the ctx were 2-3 min apart, and 60-90 seconds long. You will probably be in transition or close to birth by the time you get there, and should have a lovely birth...Man, that's scary...aren't there any Greek midwives?
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#22 of 24 Old 06-05-2008, 04:18 AM
 
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Jump ship, go for the new doc- I've been to several births that changed last minute over docs refusing to acknowledge moms concerns, and regardless of the birth route/epis or not/labor challenges I've always seen moms who were glad they did what they felt best about and didn't get scared into whatever doc 1 wanted. You are not the first, or the last to jump practices at a late date, and nay doc who won't even discuss your concerns isn;t the one to entrust your health to. I hope you have the birth you want, and the best birth possible for your baby!

And remember, if you are spooked by something big in early labor, you can always show up at the closer hospital, but odds are you won't need to, and you'll feel better about the doc that listened to you & gave you a fair shot,
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#23 of 24 Old 06-05-2008, 11:38 AM
 
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Jump ship, go for the new doc- I've been to several births that changed last minute over docs refusing to acknowledge moms concerns, and regardless of the birth route/epis or not/labor challenges I've always seen moms who were glad they did what they felt best about and didn't get scared into whatever doc 1 wanted. You are not the first, or the last to jump practices at a late date, and nay doc who won't even discuss your concerns isn;t the one to entrust your health to. I hope you have the birth you want, and the best birth possible for your baby!

And remember, if you are spooked by something big in early labor, you can always show up at the closer hospital, but odds are you won't need to, and you'll feel better about the doc that listened to you & gave you a fair shot,
I agree with this poster!

I hear from clients who change to new doctors or midwives at the last minute (sometimes at 40 weeks!) for all types of reasons, none have ever regretted the decision changing providers. Even if you have the same outcome. It is the attitude, style of care and you deserve to have the new provider. Will make you feel empowered to make this decision.

Tell us, how you're doing ?
Is you're husband giving you a hard time now?
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#24 of 24 Old 06-06-2008, 11:20 PM
 
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No advice, just wanted to share my experience in a similiar situation...

I was pregnant with my third baby and had a 20wk u/s. Found the placenta to be touching the cervix, but felt pretty confident that it would resolve itself. I had a repest u/s at 32 weeks (I think) and it was not touching, but still very low...I did not find out a measurement, no one made a big deal about it, so I didn't either. The pregnancy progressed just normally.

At 39 weeks I was in bed at 5:30 AM and I thought my water had broken...big puddle...I was half asleep, so I wasn't sure if I was dreaming or awake LOL!!! I reached down to see if the bed was wet, and the consistency did not feel like water...I yelled at dh to turn on the light, sure enough it was blood...and lots of it.

I ran for the toilet and huge gushes of blood came. I thought I had an abruption. I grabbed my doppler and listened and got the heartbeat right away, so it was time to rush to the hospital. I put on 2 postpartum pads and got ready for the hour drive to the hospital.

On the way, I had resigned myself to a C-section, knowing then that it was the least of my worries. I called the dr. and he was ready to meet me there. My baby got the hiccups, and somehow that made me feel like everything would be ok...

I got out of the car and onto a bed, I had totally bled through the pads. I was rughed to the maternity floor. They hooked up the monitors, baby looked great I was having mild contractions. Dr. came in and asked what I wanted to do...I asked him to check my cervix and see where I was...he said he would also like to see if he could feel the placenta near my cervix...I told him that was fine.

I was 2-3 cm and he could feel the placenta right beside the cervix. He said I could do whatever I wanted to do as long as baby was doing fine. I decided I was not comfortable losing that much blood for much longer, and I really thought that if I got started laboring it would be finished quickly, as my other 2 births were really fast...so I took a chance and had him break my water...

I began harder contrax. within a half an hour, and when I got to 6cm (about an hour after water was broken) I stopped bleeding. I guess her head kinda blocked it off...from then it only took a few minutes until I was ready to push...a few pushes and she was born, perfectly healthy. My labor actually went very smoothly.

I lost a good bit of blood after the birth, I actually asked the dr. if he was going to give me pitocin, I wanted the bleeding to stop! It took almost 8 hours for me to have enough strength to get out of bed, but I did not need a transfusion...

I was really frightened at the amount of blood loss, but it felt so good to know that my choices were not taken from me...I certainly felt limited in what I was comfortable doing, and that labor did take a different perspective for me, but it felt great to know that my dr. wasn't telling me what I had to do...he never once mentioned a c section. I asked him if I should have one, and he said "only if you think it is best for you and your baby, I am comfortable with your decision either way as long as you are both doing well". I totally respect that!

I had worked as a doula with this dr. many times before, and he knew very clearly what my philosophy on birth was, and he didn't make me feel wrong at all. Later when we talked about it, he said he was pretty nervous when I called him with the news that I was bleeding heavily because he knew I had to be in a dire situation to consider it an emergency...he said it was one of those calls that you dread getting...he then told me that he was surprised that the birth turned out ok, he expected it to end in an emergency...

Anyway...my longwinded story is not intended to frighten, I actually would make the same choices again if I were given that situation again...I have nothing I would change. I just wanted to share our situation, and share how much the dr. mentality played a part in how the birth went...he could have made a quick and pretty easy decision and convinced me with ease to have a c section, but instead his supportive attitude was great...I would always go with the supportive one...
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